5. Special considerations during surgery

As you plan your surgery, there are some important aspects you may want to take into consideration that will surely affect the course of your performance. First, the incisions you plan are important, because you need the best exposure you can get with the incision you

Figure 1. Use of microscope, microsurgical instruments, hand table and controlled ischemia of the hand during surgery.

plan. Other important questions are as follows: What type of anesthesia will you use? Will you use local anesthesia? What nerves will you anesthetize? What is the type and duration of ischemia of the hand? Will you have pauses between periods of ischemia? At what pressure will the tourniquet be inflated? Is a microscope needed for the procedure? Is there any special equipment or instruments you may need? Do you need microsurgical instruments? Do you need equipment for bony fixation? Do you have your surgical loupes or some kind of magnification? Will you need X-rays to be taken after bony fixation? Is every suture you are going to need ready? What type of cast or immobilization will you use after the procedure? These questions ideally must be answered during your planning as if it was a checklist so it will be easier for you to make sure everything is ready before the surgery takes place (Figure 1).

#### 6. Post-operatory care

2. Performing the right surgery

the best results possible.

4 Essentials of Hand Surgery

3. Diagnostic methods

and unnecessary studies.

4. Planning the operation

As in every aspect of medicine, the key to success in hand surgery is to make an accurate diagnosis based on a complete history and physical examination of our patient. Once you have an exact diagnosis you will know exactly what to operate and most importantly when to perform that operation. We, as surgeons, have that rush to try to solve everything as soon as it is presented to us. We know we can solve things, but we also have to be very patient to know the perfect timing and when to do it in order for our surgeries to be successful and to achieve

Besides our own eyes and hands, there are some other special diagnostic tests we can use in order to finally determine the exact problem. One of the most common and routinely performed tests are simple plain hand X-rays. As we know, the hand is a complex structure where many anatomic elements interact with each other. It is not just skin and subcutaneous tissue; we have bones, ligaments, tendons, nerves, arteries, veins, muscles, and joints that when acting together the hand will achieve a normal and complete function. There are some other special tests that can be asked in some special situations, like CT scans, MRI, electromyography, nerve conduction studies, Doppler ultrasound, and so on. As we have said the diagnosis must be made by us, not be expected to pop out spontaneously by some random

Once you have an accurate diagnosis it is plan for the next step, planning the operation. It is not enough for a hand surgeon to have just a plan for the surgery. You must have a plan B and a plan C and just as many as you need in order to act if something goes wrong. It is just not a matter of performing the surgery; it is a matter of knowing what to do and how to do it. From the incision planning to the closure of the skin, each step must be taken into consideration. Even though you are an experienced hand surgeon, our advice is to always plan your surgery the night before you perform it when it is possible. There is no small surgery; even the ones

As you plan your surgery, there are some important aspects you may want to take into consideration that will surely affect the course of your performance. First, the incisions you plan are important, because you need the best exposure you can get with the incision you

considered "easy" could turn into difficult challenges for the surgical team [2].

5. Special considerations during surgery

Once you have completed your surgery, you have to decide if your patient may need a special rehabilitation program so he or she can get the best functional result possible. For some procedures, it would just be enough with some exercises the patient can perform at home. For some others, you may need special casts or immobilization, followed by specialized hand therapy. It is important to discuss these questions with the patient before the procedure takes place. As I usually say to my patients, the results depend 50% in the surgery itself, and the other 50% will depend on the patient itself and on the hand therapist. This specialized work is not just a one-day job. It is mandatory that the hand surgeon reevaluates his patient as many times as needed until his or her function has been completely reestablished.
